This document presents the Tokyo Guidelines 2018 (TG18) for antimicrobial therapy for acute cholangitis and cholecystitis. It summarizes the microbiology of these infections, including that Escherichia coli is most commonly isolated. It emphasizes monitoring local antimicrobial resistance rates, as extended-spectrum beta-lactamase and carbapenemase producing bacteria are increasingly reported. The guidelines provide recommendations for empiric antimicrobial therapy by class and infection severity grade based on a systematic review of evidence. It recommends choosing agents based on local antibiograms and de-escalating once culture results are available.
GuÍas de Tokyo 2018 para terapia atb para colangitis aguda y colecistitisAlvaro Oyarce Calderón
This document presents guidelines for antimicrobial therapy for acute cholangitis and cholecystitis from the Tokyo Guidelines 2018 (TG18). It discusses the role of antimicrobial therapy in managing these conditions and providing source control. Common bacteria involved are outlined. It emphasizes monitoring local antimicrobial resistance patterns when selecting empirical therapy. TG18 endorses the list of appropriate antimicrobial agents from TG13 for both community-acquired and healthcare-associated infections based on a review finding no significant new evidence. Prudent antimicrobial use and early de-escalation are important considerations.
Optimal treatment strategy for acute cholecystitis based on predictive factorsmailsindatos
This article summarizes the results of a large, international multicenter retrospective study examining optimal treatment strategies for acute cholecystitis. The study included over 5,000 patients from Japan and Taiwan who were divided into four treatment groups: primary cholecystectomy, cholecystectomy after gallbladder drainage, gallbladder drainage alone, or medical treatment alone. The study found significant differences in mortality rates between patients with low versus high Charlson comorbidity index scores. For less severe cases, factors like low BMI and higher CCI predicted higher mortality. For severe cases, jaundice, neurological or respiratory dysfunction predicted higher mortality. The study concluded that even for severe cases without predictive factors, primary cholecystectomy can be performed safely
Charcot's triad shows high specificity but low sensitivity for diagnosing acute cholangitis. It is not suitable as the sole diagnostic criteria. The updated Tokyo Guidelines (TG13) establish a diagnosis of acute cholangitis when cholestasis and inflammation are demonstrated by clinical signs or blood tests, in addition to biliary manifestations shown by imaging. TG13 has higher sensitivity and specificity than the previous TG07 criteria. TG13 severity is classified as Grade III (organ failure), Grade II (early drainage needed), or Grade I (others). Grade II is diagnosed if two of five predictive poor prognosis factors are present.
Initial medical treatment for acute cholangitis includes fasting, sufficient fluid infusion, electrolyte correction, administration of antimicrobial and analgesic agents, and monitoring of respiratory and hemodynamic stability in preparation for potential emergency biliary drainage. For mild acute cholangitis, initial medical treatment may be sufficient, but biliary drainage should be considered for those not responding to medical therapy. Early biliary drainage along with antibiotics is recommended for moderate acute cholangitis. Severe cases require organ support and urgent biliary drainage after hemodynamic stabilization.
This study analyzed data from over 1,400 patients hospitalized for hepatorenal syndrome (HRS) in Japan between 2010-2019 using a national inpatient database. The results showed that 65.5% of patients died or underwent liver transplantation. Patients in this group had more advanced liver disease, were more likely to be male, and had higher rates of complications like hepatocellular carcinoma and spontaneous bacterial peritonitis. Over half of all patients received albumin therapy, while noradrenaline and dopamine were used as vasoconstrictors, with dopamine being more common than noradrenaline in clinical practice despite guidelines recommending noradrenaline. Mortality from HRS in Japan remains high.
This systematic review and meta-analysis compares appendectomy (ST) to antibiotic therapy (AT) for uncomplicated acute appendicitis (AA) in adults. Five randomized controlled trials with 1,351 patients were included. The analysis found higher treatment efficacy based on 1-year follow-up for ST (98.3%) compared to AT (75.9%). AT was associated with higher rates of complicated appendicitis with peritonitis identified at surgery (19.9% for AT vs 8.5% for ST). No significant differences were found for post-intervention complications, length of hospital stay, or period of sick leave. The review concludes that while AT may be considered for select patients, appende
This study analyzed urine samples from 1,670 patients in rural Odisha, India to determine the prevalence and etiology of community-acquired urinary tract infections (CA-UTIs). The key findings were:
1) The overall prevalence of CA-UTI was 34.5%, significantly higher in females (45.2%) than males (18.4%). Young women aged 18-37 and elderly men aged 68+ had the highest prevalence.
2) Escherichia coli was the most common causative organism (68.8%), followed by Enterococcus species. Gram-negative rods accounted for 78.2% of isolates.
3) Amikacin and nitrofurant
Tokyo guidelines for cholangitis and cholecystitis Thorsang Chayovan
The document presents the Tokyo Guidelines for the management of acute cholangitis and cholecystitis. It was created by an international working group to address the lack of standardized diagnostic criteria and treatment guidelines for biliary infections. The working group conducted an extensive literature review, found little high-level evidence, and thus developed the guidelines through international consensus meetings. The Tokyo Guidelines provide evidence-based diagnostic criteria, severity assessments, and management recommendations for acute cholangitis and cholecystitis. They aim to establish international standards for evaluating and treating biliary infections.
GuÍas de Tokyo 2018 para terapia atb para colangitis aguda y colecistitisAlvaro Oyarce Calderón
This document presents guidelines for antimicrobial therapy for acute cholangitis and cholecystitis from the Tokyo Guidelines 2018 (TG18). It discusses the role of antimicrobial therapy in managing these conditions and providing source control. Common bacteria involved are outlined. It emphasizes monitoring local antimicrobial resistance patterns when selecting empirical therapy. TG18 endorses the list of appropriate antimicrobial agents from TG13 for both community-acquired and healthcare-associated infections based on a review finding no significant new evidence. Prudent antimicrobial use and early de-escalation are important considerations.
Optimal treatment strategy for acute cholecystitis based on predictive factorsmailsindatos
This article summarizes the results of a large, international multicenter retrospective study examining optimal treatment strategies for acute cholecystitis. The study included over 5,000 patients from Japan and Taiwan who were divided into four treatment groups: primary cholecystectomy, cholecystectomy after gallbladder drainage, gallbladder drainage alone, or medical treatment alone. The study found significant differences in mortality rates between patients with low versus high Charlson comorbidity index scores. For less severe cases, factors like low BMI and higher CCI predicted higher mortality. For severe cases, jaundice, neurological or respiratory dysfunction predicted higher mortality. The study concluded that even for severe cases without predictive factors, primary cholecystectomy can be performed safely
Charcot's triad shows high specificity but low sensitivity for diagnosing acute cholangitis. It is not suitable as the sole diagnostic criteria. The updated Tokyo Guidelines (TG13) establish a diagnosis of acute cholangitis when cholestasis and inflammation are demonstrated by clinical signs or blood tests, in addition to biliary manifestations shown by imaging. TG13 has higher sensitivity and specificity than the previous TG07 criteria. TG13 severity is classified as Grade III (organ failure), Grade II (early drainage needed), or Grade I (others). Grade II is diagnosed if two of five predictive poor prognosis factors are present.
Initial medical treatment for acute cholangitis includes fasting, sufficient fluid infusion, electrolyte correction, administration of antimicrobial and analgesic agents, and monitoring of respiratory and hemodynamic stability in preparation for potential emergency biliary drainage. For mild acute cholangitis, initial medical treatment may be sufficient, but biliary drainage should be considered for those not responding to medical therapy. Early biliary drainage along with antibiotics is recommended for moderate acute cholangitis. Severe cases require organ support and urgent biliary drainage after hemodynamic stabilization.
This study analyzed data from over 1,400 patients hospitalized for hepatorenal syndrome (HRS) in Japan between 2010-2019 using a national inpatient database. The results showed that 65.5% of patients died or underwent liver transplantation. Patients in this group had more advanced liver disease, were more likely to be male, and had higher rates of complications like hepatocellular carcinoma and spontaneous bacterial peritonitis. Over half of all patients received albumin therapy, while noradrenaline and dopamine were used as vasoconstrictors, with dopamine being more common than noradrenaline in clinical practice despite guidelines recommending noradrenaline. Mortality from HRS in Japan remains high.
This systematic review and meta-analysis compares appendectomy (ST) to antibiotic therapy (AT) for uncomplicated acute appendicitis (AA) in adults. Five randomized controlled trials with 1,351 patients were included. The analysis found higher treatment efficacy based on 1-year follow-up for ST (98.3%) compared to AT (75.9%). AT was associated with higher rates of complicated appendicitis with peritonitis identified at surgery (19.9% for AT vs 8.5% for ST). No significant differences were found for post-intervention complications, length of hospital stay, or period of sick leave. The review concludes that while AT may be considered for select patients, appende
This study analyzed urine samples from 1,670 patients in rural Odisha, India to determine the prevalence and etiology of community-acquired urinary tract infections (CA-UTIs). The key findings were:
1) The overall prevalence of CA-UTI was 34.5%, significantly higher in females (45.2%) than males (18.4%). Young women aged 18-37 and elderly men aged 68+ had the highest prevalence.
2) Escherichia coli was the most common causative organism (68.8%), followed by Enterococcus species. Gram-negative rods accounted for 78.2% of isolates.
3) Amikacin and nitrofurant
Tokyo guidelines for cholangitis and cholecystitis Thorsang Chayovan
The document presents the Tokyo Guidelines for the management of acute cholangitis and cholecystitis. It was created by an international working group to address the lack of standardized diagnostic criteria and treatment guidelines for biliary infections. The working group conducted an extensive literature review, found little high-level evidence, and thus developed the guidelines through international consensus meetings. The Tokyo Guidelines provide evidence-based diagnostic criteria, severity assessments, and management recommendations for acute cholangitis and cholecystitis. They aim to establish international standards for evaluating and treating biliary infections.
Abdominal Tuberculosis Revisited–A single institutional experience of 72 case...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Evaluation of Prescribing Patterns of Antibiotics in General Medicine Ward in...ijtsrd
Knowledge about antibiotic utilization and resistance patterns of most common microorganisms are unavailable in tertiary care hospitals. To assess the pattern of antibiotic utilization and outcome of patients in a General Medical Ward, all positive blood cultures BC over a 4 month period from July 2019 to October 2019 were retrospectively reviewed. Sixty five positive BC were recorded in which patients 43 males and 22 females . 72 of the patients received antibiotics before or soon after obtaining the BC, and ceftriaxone was the most frequently prescribed antibiotic 41.93 , either alone or in combination with other antibiotics. The bacteraemia was due to gram positive cocci in 60.46 of cases, gram negative rods in 30.23 , and gram positive rods in 9.30 . Positive BC due to contamination was not included. The most common gram positive cocci were Staphylococcus epidermidis, followed by S. aureus, while the most common gram negative bacilli were Brucella species, Proteus mirabilis, and Klebsiella sp. The suspected sources of the bacteraemia were respiratory 21.2 , urinary 19.2 , or skin 19.2 . A subsequent change in the antibiotics regimen was done in 69.76 cases after BC results became available with no apparent effect on the outcome. Adding Cefotaxime, Amoxicillin clavulonic acid, piperacillintazobactum, vancomycin and clindamycin was the most frequent change done 19.4 for each equally . Complications developed in 69.76 of patients, with 88.66 of them suffering from sepsis shock. 69.23 of the patients improved and 30.77 expired death was related to infection in 87.5 of cases. In conclusion, most bacteremia in the medical ward of the hospital were due to gram positive cocci, which should be considered in antibiotic selection prior to BC. Vageeshwari Devuni | Debabrata Chaudhary "Evaluation of Prescribing Patterns of Antibiotics in General Medicine Ward in a Tertiary Care Hospital" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-4 | Issue-1 , December 2019, URL: https://www.ijtsrd.com/papers/ijtsrd29618.pdf Paper URL: https://www.ijtsrd.com/pharmacy/pharmacology-/29618/evaluation-of-prescribing-patterns-of-antibiotics-in-general-medicine-ward-in-a-tertiary-care-hospital/vageeshwari-devuni
This document summarizes revisions made to the 2018 Tokyo Guidelines (TG18) for diagnosing and grading the severity of acute cholecystitis. It reviews evidence from studies published since the 2013 Tokyo Guidelines (TG13) that validated the diagnostic criteria and severity grading system of TG13. While few new studies of the diagnostic criteria were found, several validated the TG13 severity grading as predictive of outcomes like mortality, hospital stay, and conversion to open surgery. As a result, the committee recommended adopting the same diagnostic criteria and severity grading of TG13 for TG18, without modifications, given the lack of stronger evidence proposing changes.
This document summarizes a study on the effects of major autohemotherapy with ozone on patients with chronic hepatitis B. 28 patients received 15 sessions of major autohemotherapy with increasing ozone doses up to 12,000 micrograms, as well as maintenance doses every 15 days for a year. The results showed that all patients tested negative for hepatitis B surface antigen and positive for hepatitis B surface antibody after one month of treatment. Patients also had undetectable viral loads and normal liver enzyme levels after one month, which were maintained after 6 months and 1 year. The study concludes that major autohemotherapy shows promise as an effective treatment for chronic hepatitis B through its immunomodulatory effects.
This study compared outcomes of patients with MDR/XDR Acinetobactor baumannii pneumonia treated with tigecycline or colistin. 70 patients received either tigecycline (n=30) or colistin (n=40). There were no significant differences in clinical outcomes between the two groups except nephrotoxicity, which only occurred in the colistin group. While the study indicates comparable efficacy, limitations include its small size, retrospective design, and exclusions. Further large randomized studies are still needed to properly evaluate tigecycline and optimal treatment combinations for MDR infections.
1) Empirical antibiotic therapy is initiated prior to determining the specific infecting microorganism in patients with septic shock. Inappropriate empirical therapy is associated with increased mortality.
2) Therapies should be broad-spectrum and cover likely pathogens based on infection site and patient risk factors. They should be reassessed and narrowed once culture results are available.
3) Antibiotics should be administered within 1 hour of recognizing septic shock, as delays in treatment are associated with increased mortality. Prompt administration of appropriate empirical therapy improves survival in septic shock.
Journal club Probiotics .pptx in Post op Patients of Gastroduodenal perforati...DrAshishBhardwaj1
This study aimed to evaluate if probiotics aid in the recovery of gastrointestinal motility after surgery for gastro-duodenal perforation peritonitis. 88 patients who underwent emergency surgery for this condition were randomized to receive probiotics or not after surgery. Results found no significant differences between the groups in time to first bowel sounds or flatus, white blood cell counts, complications, length of stay, or mortality. While probiotics have shown benefits after elective abdominal surgeries, this study found no advantages of probiotics for recovery after emergency surgery for perforated gastro-duodenal perforation peritonitis.
This document provides a consensus on the management of urinary tract infections (UTIs) in solid organ transplant recipients from experts in Spain. It summarizes recommendations on screening and treatment of asymptomatic bacteriuria, prophylaxis and treatment of UTIs, management of recurrent UTIs, and interactions between antimicrobials and immunosuppressants. The recommendations are based on a systematic review of the literature and provide evidence levels for each. The goal is to support optimal care of this patient population by incorporating the latest scientific evidence on UTIs in transplant recipients.
Effect of Jianpi-yangwei decoction on gut fungi in the patients with gastric ...LucyPi1
Abstract Background: Our previous study shows that the empirical formula of Chinese medicine Jianpi-yangwei decoction (JYD) can improve the quality of life in patients with gastric cancer undergoing chemotherapy by increasing beneficial gut bacteria and decreasing harmful bacteria. The present study aims to investigate the effect of JYD on gut fungi in patients with gastric cancer undergoing chemotherapy. Methods: A total of 73 patients with gastric cancer undergoing chemotherapy were recruited. Twenty-nine patients in the chemotherapy group were given standard chemotherapy and 44 patients in the observation group were given JYD plus standard chemotherapy. A control group (55 cases) was recruited from the healthy medical examiners. After 3 months of treatment, life-quality score was evaluated and fecal microbiota was tested by high-throughput sequencing based on the 18S rRNA gene. Results: After treatment, life-quality score in the observation group was significantly lower than that in the chemotherapy group (P < 0.05). There was no significant difference between the observation and control groups’ diversity and richness indices of intestinal fungi. The Chao index for intestinal fungi in the chemotherapy group was significantly lower than that in the observation group (P < 0.05). There was a significant difference between the control and chemotherapy groups in the intestinal fungi according to Shannon and Simpson indices (P < 0.05). Linear discriminant analysis effect size analysis showed no significant differences among the three groups, but significant difference in intestinal fungi was observed between the observation group and the chemotherapy group. At the genus level, the relative abundance of the Aspergillus genus in the observation and control groups was significantly lower (P < 0.05), the relative abundance of the Cutaneotrichosporon, Galactomyces, and Ganoderma genus taxa was significantly higher compared with those in the chemotherapy group (P < 0.05), and there was no significant difference between the observation group and control group. Conclusion: JYD can ameliorate chemotherapy-induced fungal dysbacteriosis in patients with gastric cancer undergoing chemotherapy and improve the quality of life of patients.
1. The document discusses the roles of biomedical scientists in disease detection and management through various tests and investigations. It covers topics like whole population screening, disease diagnosis, monitoring, and discusses tests in pathology disciplines like immunopathology and hematology.
2. It also discusses non-biomedical investigations like blood pressure measurement, electromyography, and magnetic resonance imaging.
3. Specifically, it discusses myocardial infarction - the signs and symptoms are analyzed using electrocardiograms, blood tests to detect cardiac troponin, and other biomarkers to confirm the diagnosis.
Sepsis is a life-threatening condition caused by a dysregulated immune response to infection that can lead to organ dysfunction. It is a major public health challenge worldwide with high mortality rates. The pathophysiology of sepsis involves an initial hyperinflammatory state followed by immune suppression that increases susceptibility to secondary infections. Biomarkers such as C-reactive protein and procalcitonin can help diagnose sepsis and evaluate severity, but an ideal biomarker has yet to be identified. Treatment of sepsis involves both resuscitative strategies and infection control according to surviving sepsis guidelines, and focuses on the complex pathophysiology of the condition.
This study aims to determine if active negative pressure peritoneal therapy reduces inflammation more than standard temporary abdominal closure. The study will randomize adult patients requiring damage control laparotomy to closure with either an ABThera system providing active negative pressure, or a Barker's vacuum pack providing less efficient pressure. Blood and fluid samples will quantify inflammatory markers to compare the treatments' effects on the inflammatory response and patient outcomes. Results could improve understanding of negative pressure therapy and inform a larger trial.
This study evaluated the efficacy and safety of intravenous injection of Mycobacterium w (Mw) in treating gram-negative sepsis.
The study involved 30 patients over 18 years of age with gram-negative sepsis and single organ dysfunction. Patients received intravenous Mw injections in addition to standard care. Results showed significant improvements in vital signs, organ function markers, and sepsis severity scores from day 2 onward compared to baseline. No major adverse events occurred.
The study concluded that intravenous Mw appears to be a well-tolerated and effective adjuvant treatment for gram-negative sepsis when added to standard care, as demonstrated by improved clinical outcomes. However, larger randomized controlled trials are still needed to confirm these findings.
The Role Bacteria Biofilm Have in Identifying, Classifying and Defining UTI in Laboratory and Clinical Screenings of NB Patients That Use CIC in Clinical Settings
Treatment of COVID-19; old tricks for new challengesLuisaSarlat
Coronavirus disease (COVID-19), which appeared in December 2019, presents a global challenge, particularly in the rapid increase of critically ill patients with pneumonia and absence of definitive treatment. To date, over 81,000 cases have been confirmed, with over 2700 deaths. The mortality appears to be around 2%; early published data indicate 25.9% with SARS-CoV-2 pneumonia required ICU admission and 20.1% developed acute respiratory distress syndrome
This study evaluated the initial management of sepsis patients in a tertiary care center in India. A total of 100 sepsis cases were reviewed. The most common comorbidities were diabetes, hypertension, and hypothyroidism. The majority (78%) had sepsis, while 22% had septic shock. Common infection sources were lower respiratory tract (41%) and urinary tract (19%). Most patients received appropriate antibiotics within 1 hour as per guidelines. Fluid therapy was administered to 78% of patients and vasoactive medications were given to all with septic shock. Overall adherence to sepsis management guidelines was found to be satisfactory, though some areas for improvement were identified.
Effect of Antibiotics on The Gut Microbiota in Children with Chronic Pancreat...JohnJulie1
Little is known about the effect of antibiotic treatment on the gut microbiota in children with chronic pancreatitis (CCP). Our objective was to identify the effect of antibiotic treatment on the gut microbiota in children with chronic pancreatitis (CCP), the main gut microbiota genera and characterize the patients’ functional mutations after using antibiotics.
Need of Dual Antiviral Treatment in Chronic Hepatitis BJohnJulie1
The primary indication for an esophagectomy is esophageal cancer or Barrett’s esophagus with high-grade dysplasia. Patients undergoing esophagectomy often present with dysphagia, side effects from chemotherapy, decreased appetite, and weight loss. Esophagectomy may be an operation involving the abdomen, neck, and/or chest requiring 5 to 7 days of NPO status to permit healing of the anastomosis between the upper esophagus and new esophageal conduit (usually the stomach).
Need of Dual Antiviral Treatment in Chronic Hepatitis BJohnJulie1
Approximately one third of the world’s population has serological evidence of past or present infection with the hepatitis B virus (HBV). An estimated 350-400 million people are surface HBV antigen (HBsAg) carriers. India has 40 million HBV carriers i.e. 10–15% share of total pool of HBV carriers of the world. In India.
Approximately one third of the world’s population has serological evidence of past or present infection with the hepatitis B virus (HBV). An estimated 350-400 million people are surface HBV antigen (HBsAg) carriers. India has 40 million HBV carriers i.e. 10–15% share of total pool of HBV carriers of the world. In India.
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
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Abdominal Tuberculosis Revisited–A single institutional experience of 72 case...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Evaluation of Prescribing Patterns of Antibiotics in General Medicine Ward in...ijtsrd
Knowledge about antibiotic utilization and resistance patterns of most common microorganisms are unavailable in tertiary care hospitals. To assess the pattern of antibiotic utilization and outcome of patients in a General Medical Ward, all positive blood cultures BC over a 4 month period from July 2019 to October 2019 were retrospectively reviewed. Sixty five positive BC were recorded in which patients 43 males and 22 females . 72 of the patients received antibiotics before or soon after obtaining the BC, and ceftriaxone was the most frequently prescribed antibiotic 41.93 , either alone or in combination with other antibiotics. The bacteraemia was due to gram positive cocci in 60.46 of cases, gram negative rods in 30.23 , and gram positive rods in 9.30 . Positive BC due to contamination was not included. The most common gram positive cocci were Staphylococcus epidermidis, followed by S. aureus, while the most common gram negative bacilli were Brucella species, Proteus mirabilis, and Klebsiella sp. The suspected sources of the bacteraemia were respiratory 21.2 , urinary 19.2 , or skin 19.2 . A subsequent change in the antibiotics regimen was done in 69.76 cases after BC results became available with no apparent effect on the outcome. Adding Cefotaxime, Amoxicillin clavulonic acid, piperacillintazobactum, vancomycin and clindamycin was the most frequent change done 19.4 for each equally . Complications developed in 69.76 of patients, with 88.66 of them suffering from sepsis shock. 69.23 of the patients improved and 30.77 expired death was related to infection in 87.5 of cases. In conclusion, most bacteremia in the medical ward of the hospital were due to gram positive cocci, which should be considered in antibiotic selection prior to BC. Vageeshwari Devuni | Debabrata Chaudhary "Evaluation of Prescribing Patterns of Antibiotics in General Medicine Ward in a Tertiary Care Hospital" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-4 | Issue-1 , December 2019, URL: https://www.ijtsrd.com/papers/ijtsrd29618.pdf Paper URL: https://www.ijtsrd.com/pharmacy/pharmacology-/29618/evaluation-of-prescribing-patterns-of-antibiotics-in-general-medicine-ward-in-a-tertiary-care-hospital/vageeshwari-devuni
This document summarizes revisions made to the 2018 Tokyo Guidelines (TG18) for diagnosing and grading the severity of acute cholecystitis. It reviews evidence from studies published since the 2013 Tokyo Guidelines (TG13) that validated the diagnostic criteria and severity grading system of TG13. While few new studies of the diagnostic criteria were found, several validated the TG13 severity grading as predictive of outcomes like mortality, hospital stay, and conversion to open surgery. As a result, the committee recommended adopting the same diagnostic criteria and severity grading of TG13 for TG18, without modifications, given the lack of stronger evidence proposing changes.
This document summarizes a study on the effects of major autohemotherapy with ozone on patients with chronic hepatitis B. 28 patients received 15 sessions of major autohemotherapy with increasing ozone doses up to 12,000 micrograms, as well as maintenance doses every 15 days for a year. The results showed that all patients tested negative for hepatitis B surface antigen and positive for hepatitis B surface antibody after one month of treatment. Patients also had undetectable viral loads and normal liver enzyme levels after one month, which were maintained after 6 months and 1 year. The study concludes that major autohemotherapy shows promise as an effective treatment for chronic hepatitis B through its immunomodulatory effects.
This study compared outcomes of patients with MDR/XDR Acinetobactor baumannii pneumonia treated with tigecycline or colistin. 70 patients received either tigecycline (n=30) or colistin (n=40). There were no significant differences in clinical outcomes between the two groups except nephrotoxicity, which only occurred in the colistin group. While the study indicates comparable efficacy, limitations include its small size, retrospective design, and exclusions. Further large randomized studies are still needed to properly evaluate tigecycline and optimal treatment combinations for MDR infections.
1) Empirical antibiotic therapy is initiated prior to determining the specific infecting microorganism in patients with septic shock. Inappropriate empirical therapy is associated with increased mortality.
2) Therapies should be broad-spectrum and cover likely pathogens based on infection site and patient risk factors. They should be reassessed and narrowed once culture results are available.
3) Antibiotics should be administered within 1 hour of recognizing septic shock, as delays in treatment are associated with increased mortality. Prompt administration of appropriate empirical therapy improves survival in septic shock.
Journal club Probiotics .pptx in Post op Patients of Gastroduodenal perforati...DrAshishBhardwaj1
This study aimed to evaluate if probiotics aid in the recovery of gastrointestinal motility after surgery for gastro-duodenal perforation peritonitis. 88 patients who underwent emergency surgery for this condition were randomized to receive probiotics or not after surgery. Results found no significant differences between the groups in time to first bowel sounds or flatus, white blood cell counts, complications, length of stay, or mortality. While probiotics have shown benefits after elective abdominal surgeries, this study found no advantages of probiotics for recovery after emergency surgery for perforated gastro-duodenal perforation peritonitis.
This document provides a consensus on the management of urinary tract infections (UTIs) in solid organ transplant recipients from experts in Spain. It summarizes recommendations on screening and treatment of asymptomatic bacteriuria, prophylaxis and treatment of UTIs, management of recurrent UTIs, and interactions between antimicrobials and immunosuppressants. The recommendations are based on a systematic review of the literature and provide evidence levels for each. The goal is to support optimal care of this patient population by incorporating the latest scientific evidence on UTIs in transplant recipients.
Effect of Jianpi-yangwei decoction on gut fungi in the patients with gastric ...LucyPi1
Abstract Background: Our previous study shows that the empirical formula of Chinese medicine Jianpi-yangwei decoction (JYD) can improve the quality of life in patients with gastric cancer undergoing chemotherapy by increasing beneficial gut bacteria and decreasing harmful bacteria. The present study aims to investigate the effect of JYD on gut fungi in patients with gastric cancer undergoing chemotherapy. Methods: A total of 73 patients with gastric cancer undergoing chemotherapy were recruited. Twenty-nine patients in the chemotherapy group were given standard chemotherapy and 44 patients in the observation group were given JYD plus standard chemotherapy. A control group (55 cases) was recruited from the healthy medical examiners. After 3 months of treatment, life-quality score was evaluated and fecal microbiota was tested by high-throughput sequencing based on the 18S rRNA gene. Results: After treatment, life-quality score in the observation group was significantly lower than that in the chemotherapy group (P < 0.05). There was no significant difference between the observation and control groups’ diversity and richness indices of intestinal fungi. The Chao index for intestinal fungi in the chemotherapy group was significantly lower than that in the observation group (P < 0.05). There was a significant difference between the control and chemotherapy groups in the intestinal fungi according to Shannon and Simpson indices (P < 0.05). Linear discriminant analysis effect size analysis showed no significant differences among the three groups, but significant difference in intestinal fungi was observed between the observation group and the chemotherapy group. At the genus level, the relative abundance of the Aspergillus genus in the observation and control groups was significantly lower (P < 0.05), the relative abundance of the Cutaneotrichosporon, Galactomyces, and Ganoderma genus taxa was significantly higher compared with those in the chemotherapy group (P < 0.05), and there was no significant difference between the observation group and control group. Conclusion: JYD can ameliorate chemotherapy-induced fungal dysbacteriosis in patients with gastric cancer undergoing chemotherapy and improve the quality of life of patients.
1. The document discusses the roles of biomedical scientists in disease detection and management through various tests and investigations. It covers topics like whole population screening, disease diagnosis, monitoring, and discusses tests in pathology disciplines like immunopathology and hematology.
2. It also discusses non-biomedical investigations like blood pressure measurement, electromyography, and magnetic resonance imaging.
3. Specifically, it discusses myocardial infarction - the signs and symptoms are analyzed using electrocardiograms, blood tests to detect cardiac troponin, and other biomarkers to confirm the diagnosis.
Sepsis is a life-threatening condition caused by a dysregulated immune response to infection that can lead to organ dysfunction. It is a major public health challenge worldwide with high mortality rates. The pathophysiology of sepsis involves an initial hyperinflammatory state followed by immune suppression that increases susceptibility to secondary infections. Biomarkers such as C-reactive protein and procalcitonin can help diagnose sepsis and evaluate severity, but an ideal biomarker has yet to be identified. Treatment of sepsis involves both resuscitative strategies and infection control according to surviving sepsis guidelines, and focuses on the complex pathophysiology of the condition.
This study aims to determine if active negative pressure peritoneal therapy reduces inflammation more than standard temporary abdominal closure. The study will randomize adult patients requiring damage control laparotomy to closure with either an ABThera system providing active negative pressure, or a Barker's vacuum pack providing less efficient pressure. Blood and fluid samples will quantify inflammatory markers to compare the treatments' effects on the inflammatory response and patient outcomes. Results could improve understanding of negative pressure therapy and inform a larger trial.
This study evaluated the efficacy and safety of intravenous injection of Mycobacterium w (Mw) in treating gram-negative sepsis.
The study involved 30 patients over 18 years of age with gram-negative sepsis and single organ dysfunction. Patients received intravenous Mw injections in addition to standard care. Results showed significant improvements in vital signs, organ function markers, and sepsis severity scores from day 2 onward compared to baseline. No major adverse events occurred.
The study concluded that intravenous Mw appears to be a well-tolerated and effective adjuvant treatment for gram-negative sepsis when added to standard care, as demonstrated by improved clinical outcomes. However, larger randomized controlled trials are still needed to confirm these findings.
The Role Bacteria Biofilm Have in Identifying, Classifying and Defining UTI in Laboratory and Clinical Screenings of NB Patients That Use CIC in Clinical Settings
Treatment of COVID-19; old tricks for new challengesLuisaSarlat
Coronavirus disease (COVID-19), which appeared in December 2019, presents a global challenge, particularly in the rapid increase of critically ill patients with pneumonia and absence of definitive treatment. To date, over 81,000 cases have been confirmed, with over 2700 deaths. The mortality appears to be around 2%; early published data indicate 25.9% with SARS-CoV-2 pneumonia required ICU admission and 20.1% developed acute respiratory distress syndrome
This study evaluated the initial management of sepsis patients in a tertiary care center in India. A total of 100 sepsis cases were reviewed. The most common comorbidities were diabetes, hypertension, and hypothyroidism. The majority (78%) had sepsis, while 22% had septic shock. Common infection sources were lower respiratory tract (41%) and urinary tract (19%). Most patients received appropriate antibiotics within 1 hour as per guidelines. Fluid therapy was administered to 78% of patients and vasoactive medications were given to all with septic shock. Overall adherence to sepsis management guidelines was found to be satisfactory, though some areas for improvement were identified.
Effect of Antibiotics on The Gut Microbiota in Children with Chronic Pancreat...JohnJulie1
Little is known about the effect of antibiotic treatment on the gut microbiota in children with chronic pancreatitis (CCP). Our objective was to identify the effect of antibiotic treatment on the gut microbiota in children with chronic pancreatitis (CCP), the main gut microbiota genera and characterize the patients’ functional mutations after using antibiotics.
Need of Dual Antiviral Treatment in Chronic Hepatitis BJohnJulie1
The primary indication for an esophagectomy is esophageal cancer or Barrett’s esophagus with high-grade dysplasia. Patients undergoing esophagectomy often present with dysphagia, side effects from chemotherapy, decreased appetite, and weight loss. Esophagectomy may be an operation involving the abdomen, neck, and/or chest requiring 5 to 7 days of NPO status to permit healing of the anastomosis between the upper esophagus and new esophageal conduit (usually the stomach).
Need of Dual Antiviral Treatment in Chronic Hepatitis BJohnJulie1
Approximately one third of the world’s population has serological evidence of past or present infection with the hepatitis B virus (HBV). An estimated 350-400 million people are surface HBV antigen (HBsAg) carriers. India has 40 million HBV carriers i.e. 10–15% share of total pool of HBV carriers of the world. In India.
Approximately one third of the world’s population has serological evidence of past or present infection with the hepatitis B virus (HBV). An estimated 350-400 million people are surface HBV antigen (HBsAg) carriers. India has 40 million HBV carriers i.e. 10–15% share of total pool of HBV carriers of the world. In India.
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
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- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
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Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)GeorgeKieling1
Home
Organization
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
About AOMA: The Academy of Oriental Medicine at Austin offers a masters-level graduate program in acupuncture and Oriental medicine, preparing its students for careers as skilled, professional practitioners. AOMA is known for its internationally recognized faculty, award-winning student clinical internship program, and herbal medicine program. Since its founding in 1993, AOMA has grown rapidly in size and reputation, drawing students from around the nation and faculty from around the world. AOMA also conducts more than 20,000 patient visits annually in its student and professional clinics. AOMA collaborates with Western healthcare institutions including the Seton Family of Hospitals, and gives back to the community through partnerships with nonprofit organizations and by providing free and reduced price treatments to people who cannot afford them. The Academy of Oriental Medicine at Austin is located at 2700 West Anderson Lane. AOMA also serves patients and retail customers at its south Austin location, 4701 West Gate Blvd. For more information see www.aoma.edu or call 512-492-303434.
Spontaneous Bacterial Peritonitis - Pathogenesis , Clinical Features & Manage...Jim Jacob Roy
In this presentation , SBP ( spontaneous bacterial peritonitis ) , which is a common complication in patients with cirrhosis and ascites is described in detail.
The reference for this presentation is Sleisenger and Fordtran's Gastrointestinal and Liver Disease Textbook ( 11th edition ).
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Gene therapy can be broadly defined as the transfer of genetic material to cure a disease or at least to improve the clinical status of a patient.
One of the basic concepts of gene therapy is to transform viruses into genetic shuttles, which will deliver the gene of interest into the target cells.
Safe methods have been devised to do this, using several viral and non-viral vectors.
In the future, this technique may allow doctors to treat a disorder by inserting a gene into a patient's cells instead of using drugs or surgery.
The biggest hurdle faced by medical research in gene therapy is the availability of effective gene-carrying vectors that meet all of the following criteria:
Protection of transgene or genetic cargo from degradative action of systemic and endonucleases,
Delivery of genetic material to the target site, i.e., either cell cytoplasm or nucleus,
Low potential of triggering unwanted immune responses or genotoxicity,
Economical and feasible availability for patients .
Viruses are naturally evolved vehicles that efficiently transfer their genes into host cells.
Choice of viral vector is dependent on gene transfer efficiency, capacity to carry foreign genes, toxicity, stability, immune responses towards viral antigens and potential viral recombination.
There are a wide variety of vectors used to deliver DNA or oligo nucleotides into mammalian cells, either in vitro or in vivo.
The most common vector system based on retroviruses, adenoviruses, herpes simplex viruses, adeno associated viruses.
This presentation gives information on the pharmacology of Prostaglandins, Thromboxanes and Leukotrienes i.e. Eicosanoids. Eicosanoids are signaling molecules derived from polyunsaturated fatty acids like arachidonic acid. They are involved in complex control over inflammation, immunity, and the central nervous system. Eicosanoids are synthesized through the enzymatic oxidation of fatty acids by cyclooxygenase and lipoxygenase enzymes. They have short half-lives and act locally through autocrine and paracrine signaling.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Nutritional deficiency Disorder are problems in india.
It is very important to learn about Indian child's nutritional parameters as well the Disease related to alteration in their Nutrition.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
2. In the TG18 guidelines, empiric therapy is defined as
antimicrobial therapy until the cultures and susceptibility
testing results are available. Once causative microorgan-
isms and the susceptibility testing results are available,
antimicrobial therapy should be adjusted to specific
antimicrobial agents targeting the organisms. This process
is defined as de-escalation of antimicrobial therapy in the
TG18 guidelines [7].
Role of antimicrobial therapy
Acute cholangitis and cholecystitis are still fatal diseases if
not appropriately treated in a timely fashion. In previous
guidelines (TG13), we defined a severity grading system. A
recent large-scale study indicated the mortality rate (30-day
all-cause mortality rate) of 2.4%, 4.7%, 8.4% by TG13
severity grade I, II, and III, respectively [8]. For patients
with septic shock, appropriate antimicrobial therapy should
be administered within an hour [7]. For other, less acutely
ill patients, therapy should be administered within 6 h of
diagnosis. The primary goal of antimicrobial therapy in
acute cholangitis and cholecystitis is to limit both the sys-
temic septic response and local inflammation, to prevent sur-
gical site infections in the superficial wound, fascia, or organ
space, and to prevent intrahepatic abscess formation [9].
While drainage of the obstructed biliary trees (termed
source control) has been recognized as the mainstay of
the therapy for patients with acute cholangitis [9], the
roles of antimicrobial therapy for acute cholangitis is to
allow patients to have elective drainage procedures other
than emergency [10]. Boey and Way retrospectively
reviewed 99 consecutive patients with acute cholangitis,
and reported that 53% of their patients who responded
well to antimicrobial therapy were therefore provided
elective instead of emergency operation [9, 10].
For acute cholecystitis, the role of antimicrobial therapy
varies depending on the severity and pathology. In early
and non-severe cases (or patients with acute cholecystitis of
TG18 severity grade I [11]), it is not obvious that bacteria
play a significant role in the pathology encountered. In
these patients, antimicrobial therapy is at best prophylactic,
preventing progression to infection. In more progressed,
moderately severe or severe cases, with clinical findings of
a systemic inflammatory response, antimicrobial therapy is
therapeutic, and antimicrobial therapy may be required until
the gallbladder is removed [12].
Decision process
A systematic literature review was performed using
PubMed and Cochrane Clinical Controlled Trials (CCT)
and Cochrane Database of Systematic Reviews (CDSR)
from 1 January 2010 to 16 December 2016. All references
were searched with the keywords “Acute cholangitis”
AND “Antibiotics OR Antimicrobial therapy,” and “Acute
cholecystitis” AND “Antibiotics OR Antimicrobial ther-
apy” among human studies. These references were further
narrowed using “Clinical trials” and “Randomized trials.”
Literature cited in the TG07 [13, 14] and TG13 [1] was
also reviewed and integrated for revision. In making rec-
ommendations, a consensus process utilizing the GRADE
systems [15, 16] was used by the members of the Tokyo
Guidelines Revision Committee. GRADE stands for
Grades of Recommendation Assessment, Development,
and Evaluation. In the TG18 guidelines, the strength of
the recommendation was graded as 1 (strong) or 2 (weak).
The quality of the evidence was graded as high (level A),
moderate (level B), low (level C), and very low (level D).
Newly identified literatures cited in the TG18 were men-
tioned in the clinical question sections.
Microbiology of acute cholangitis and cholecystitis
The bacteria commonly found in biliary tract infections
are well known, and are presented in Tables 1 and 2 [8,
13, 14, 17–29]. A large-scale multicenter international
observational study was conducted and published in 2017
on epidemiology and microbiology among patients with
acute cholangitis [8]. In this study, the most frequently
isolated organisms were Escherichia coli across the sever-
ity grades of TG13 [30].
Local prevalence of extended-spectrum beta-lactamase and
carbapenemase producing Gram-negative bacilli
Antimicrobial therapy largely depends on local antimicro-
bial susceptibility data. The emergence of antimicrobial
resistance among clinical isolates of Enterobacteriaceae
from patients with community-acquired intra-abdominal
infections has been widely reported [29, 31–37]. Espe-
cially, extended-spectrum beta-lactamases (ESBL) and
carbapenemases (i.e. metallo-beta-lactamase and non-
metallo-beta-lactamase) producing bacilli reported [38–42]
have been significantly affecting the selection of empirical
therapy for patients with intra-abdominal infections,
including acute cholangitis and cholecystitis [43].
In selecting empirical antimicrobial therapy, special
attention should be paid to the incidence of ESBL and
carbapenemase-producing bacteria in non-urinary tract
isolates. A prospective cohort study in patients with
acute cholecystitis involving 116 institutions worldwide
showed that among 96 isolated E. coli, 16 (16.7%) were
4 J Hepatobiliary Pancreat Sci (2018) 25:3–16
3. producing ESBL [44]. However, the proportion of ESBL
producing E. coli varies widely region to region: 31.2%
in two German university hospitals [45], 70.0% in Korean
university medical center [46] and 66% in Indian medical
college hospital [47]. There are few reports about the
prevalence of carbapenem resistant bacteria specifically
among patients with acute cholangitis and cholecystitis.
One from Korea reported 13 out of 376 (3.5%) isolates in
bile were carbapenemase producing [48].
In TG18, the international practice guidelines for acute
cholangitis and cholecystitis, agents appropriate for use
are provided in Table 3 by antimicrobial class-based defi-
nitions. Table 3 has been re-evaluated with a systematic
literature review and Tokyo Guidelines Revision Commit-
tee. There was no new significant evidence to modify the
list of agents. Therefore, Table 3 has been endorsed from
TG13, Table 3 [1]. Table 3 lists antimicrobial agents
appropriate for use for the treatment of patients with both
community-acquired and healthcare-associated cholangitis
and cholecystitis.
Monitoring and updating local antibiograms are critical
to provide effective therapy in a timely fashion in the
clinical setting. We recommend that microbiology labora-
tories report resistance data by site of infection, and
include biliary infections with other intra-abdominal infec-
tions. We also recommend empiric therapy for resistant
isolates if they occur in more than 20% of patients [49].
In particular, ampicillin/sulbactam can be used as initial
therapy if the susceptibility remains over 80% in the local
area. However, in many places of the world, its suscepti-
bility has been reported to be decreasing. Ampicillin/sul-
bactam can be used once its susceptibility is known as
definitive or targeted therapy.
Clinical questions
Clinically relevant questions are provided with brief
answers and explanations below.
Questions 1 and 2, and their answers and explanations
have been endorsed from TG13 Q1 and Q2 [1].
Q1. What specimen should be sent for culture to iden-
tify the causative organisms in acute cholangitis and
cholecystitis?
(Bile cultures)
Bile cultures should be obtained at the beginning of
any procedure performed. Gallbladder bile should
be sent for culture in all cases of acute cholecystitis
except those with grade I severity. (Recommenda-
tion 1, level C)
Table 2 Common isolates from patients with bacteremic biliary
tract infections (endorsed from the Tokyo Guidelines 2013 [1],
Table 2)
Isolated
microorganisms
from blood cultures
Bacteremic biliary tract infections
Community-acquired
infectionsa
Healthcare-associated
infectionsb
Proportions
of isolates (%)
Proportions
of isolates (%)
Gram-negative organisms
Escherichia coli 35–62 23
Klebsiella spp. 12–28 16
Pseudomonas spp. 4–14 17
Enterobacter spp. 2–7 7
Acinetobacter spp. 3 7
Citrobacter spp. 2–6 5
Gram-positive organisms
Enterococcus spp. 10–23 20
Streptococcus spp. 6–9 5
Staphylococcus spp. 2 4
Anaerobes 1 2
Others 17 11
Table 2 is cited from the Tokyo Guidelines 2013 (TG13) [1]. Data
from Gomi et al. [8] was integrated for the Tokyo Guidelines 2018
(TG18)
a
Data are from references [8, 25–27, 29]
b
Data are from reference [29]
Table 1 Common microorganisms isolated from bile cultures
among patients with acute biliary infections (endorsed from the
Tokyo Guidelines 2013 [1], Table 1)
Isolated microorganisms
from bile cultures
Proportions of isolated
organisms (%)
Gram-negative organisms
Escherichia coli 31–44
Klebsiella spp. 9–20
Pseudomonas spp. 0.5–19
Enterobacter spp. 5–9
Acinetobacter spp. –
Citrobacter spp. –
Gram-positive organisms
Enterococcus spp. 3–34
Streptococcus spp. 2–10
Staphylococcus spp. 0a
Anaerobes 4–20
Others –
Table 1 is cited from the Tokyo Guidelines 2013 (TG13) [1]. Data
from Rhodes et al. [7] was integrated for the Tokyo Guidelines
2018 (TG18). The data are from references [8, 13, 14, 17–24, 27]
a
A recent study by Salvador et al. [24] reported none from bile cul-
tures, while a study by Sung et al. [29] reported 3.6% from blood
cultures among community-acquired (2%) and healthcare-associated
(4%) bacteremic acute biliary infections
J Hepatobiliary Pancreat Sci (2018) 25:3–16 5
5. We suggest cultures of bile and tissue when per-
foration, emphysematous changes, or necrosis of
gallbladder are noted during cholecystectomy.
(Recommendation 2, level D)
(Blood cultures)
Blood cultures are not routinely recommended for
grade I community-acquired acute cholecystitis.
(Recommendation 2, level D)
Identifying the causative organism(s) is an essential
step for the management of acute biliary infections. Posi-
tive rates of bile cultures range from 28% to 93% for
acute cholangitis [8, 13–24] and positive rates of either
bile or gallbladder cultures range from 29% to 54% for
acute cholecystitis [13–24]. In a recent study, which used
the TG07 diagnostic classification, positive rates of bile
cultures among patients with cholangitis were 67% (66 of
98 patients) and 33% (32 of 98) without [24]. Table 1
demonstrates common microbial isolates from bile
cultures among patients with acute biliary infections [8,
13–24]. Common duct bile should be sent in all cases of
suspected cholangitis.
On the other hand, previous studies indicated that posi-
tive rates of blood cultures among patients with acute
cholangitis ranged from 21% to 71% [13]. A recent multi-
center study of patients with acute cholangitis showed the
proportions of positive blood cultures were 15.2%, 21%,
and 25.7% by TG13 severity grade I, II, and III, respec-
tively [7]. For acute cholecystitis, the prevalence of posi-
tive blood cultures is less than acute cholangitis, and in
the last two decades it has been reported to range from
7.7% to 15.8% [25, 28]. Table 2 demonstrates the most
recently reported microbial isolates from patients with
bacteremic biliary tract infections [8, 25–27, 29].
There is a lack of clinical trials examining the benefit
of blood cultures in patients with acute biliary tract infec-
tions. On the other hand, there is an argument that every
opportunity should be used to identify microorganisms
and susceptibility testing in the era of antimicrobial resis-
tance [45].
Most of the bacteremic isolates reported (Table 2) are
organisms that do not form vegetations on normal cardiac
valves or military abscesses [8]. Their intravascular pres-
ence does not lead to an extension of therapy or selection
of multidrug regimens. We therefore recommend such
cultures be taken only in high severity infections when
such results might mandate changes in therapy [3, 4, 7].
Blood cultures are not routinely recommended for grade I
community-acquired acute cholecystitis.
The SIS-NA/IDSA 2010 guidelines recommended
against routine blood cultures for community-acquired
intra-abdominal infections since the results do not change
the management and outcomes [49]. This recommendation
is carried forward in recent guidelines [43]. This is in part
driven by a study of the clinical impact of blood cultures
taken in the emergency department [51]. In this retrospec-
tive study, 1,062 blood cultures were obtained during the
study period. Among them, 92 (9%) were positive. Of the
positive blood cultures, 52 (5%) were true positive, and
only 18 (1.6%) resulted in altered management.
Q2. What considerations should be taken when select-
ing antimicrobial agents for the treatment of acute
cholangitis and cholecystitis?
When selecting antimicrobial agents, targeted
organisms, pharmacokinetics and pharmacody-
namics, local antibiogram, a history of antimicro-
bial usage, renal and hepatic function, and a
history of allergies and other adverse events should
be considered. (Recommendation 1, level D).
We suggest anaerobic therapy if a biliary-enteric
anastomosis is present. (Recommendation 2, level C)
There are multiple factors to consider in selecting
empiric antimicrobial agents. These include targeted
organisms, local epidemiology and susceptibility data (an-
tibiogram), alignment of in vitro activity (or spectrum) of
the agents with these local data, characteristics of the
agents such as pharmacokinetics and pharmacodynamics,
and toxicities, renal and hepatic function, and any history
of allergies and other adverse events with antimicrobial
agents [13, 14, 17–24]. A history of antimicrobial usage
is important because recent (<6 months) antimicrobial
therapy greatly increases the risk of resistance among iso-
lated organisms.
Renal function should be estimated before dosing
antimicrobial agents with the commonly used equation:
Serum creatinine = (140-age) (optimum body weight
(kg))/72 9 serum creatinine (mg/dl) [13, 14, 52]. Individ-
ual dosage adjustments for altered renal and hepatic func-
tion is available in several recent publications [53, 54].
Consultation with a clinical pharmacist is recommended if
there are concerns.
Regarding the timing of therapy, therapy should be ini-
tiated as soon as the diagnosis of biliary infection is sus-
pected. For patients in septic shock, antimicrobials should
be administered within 1 h of recognition [7]. For other
patients, as long as 6 h may be spent obtaining definitive
diagnostic studies prior to beginning antimicrobial
J Hepatobiliary Pancreat Sci (2018) 25:3–16 7
6. therapy. Antimicrobial therapy should definitely be started
before any procedure, either percutaneous, endoscopic, or
operative, is performed. In addition, anaerobic therapy is
appropriate if a biliary-enteric anastomosis is present [49].
Antimicrobial agents appropriate for use in the
management of community-acquired acute cholangitis
and cholecystitis
Table 3 summarizes antimicrobial recommendations [1]. It
should be kept in mind that in the treatment of cholangi-
tis, source control (i.e. drainage) is an essential part of
management. The indications and timing for drainage are
provided in the severity and flowchart of the management
sections regarding acute cholangitis [2–6]. There have
been multiple reports on clinical isolates with multiple
drug resistance from intra-abdominal infections world-
wide, and biliary infections in particular [29, 31–37, 55].
Recommendations for antimicrobial therapy are based
primarily upon extrapolations of microbiologic efficacy
and behavior of these agents against the more susceptible
isolates treated in the cited clinical trials [56–66]. Some
concerns about this approach to defining efficacy against
resistant isolates has been raised [41].
The use of severity of illness as a guide to antimicro-
bial agent selection has been questioned in the face of the
increasing numbers of ESBL-producing E. coli and Kleb-
siella in the community. These organisms are not reliably
susceptible to cephalosporins, penicillin derivatives, or flu-
oroquinolones. Previous guidelines have recommended
that if more than 10–20% of community isolates of
E. coli are so resistant, then empiric coverage should be
provided for these organisms until susceptibility data
demonstrates sensitivity to narrower spectrum agents [49].
Carbapenems, piperacillin/tazobactam, tigecycline, amika-
cin, and other newer agents such as ceftazidime/avibactum
and ceftolozane/tazobactam may also be used to treat
these isolates.
For grade III community-acquired acute cholangitis and
cholecystitis, as initial therapy (empirical therapy), agents
with anti-pseudomonal activities are recommended until
causative organisms are identified. Pseudomonas aerugi-
nosa is present in approximately 20% of previous series
[24, 29]. However, recent large-scale data showed very
few ranging from 1.1% to 3.1% among isolates from
blood cultures and 2.5% to 3.6% from bile cultures
obtained from patients with acute cholangitis, respectively
[8]. P. aeruginosa is a known virulent pathogen and fail-
ure to empirically cover this organism in critically ill
patients may result in excess mortality.
Enterococcus spp. is another important pathogen for
consideration in patients with grade III community-
acquired acute cholangitis and cholecystitis. Vancomycin
is recommended to cover Enterococcus spp. for patients
with grade III community-acquired acute cholangitis and/
or cholecystitis, until the results of cultures are available.
Ampicillin can be used if isolated strains of Enterococcus
spp. are susceptible to ampicillin. Ampicillin covers most
of the strains of Enterococcus faecalis from community-
acquired infections in general. For Enterococcus faecium,
vancomycin is the drug of choice for empirical therapy.
However, in many hospitals, vancomycin-resistant Entero-
coccus spp., both E. faecium and E. faecalis, have
emerged as important causes of infection. Treatment for
these organisms requires either linezolid or daptomycin.
Surgeons and other physicians making treatment decisions
for patients with healthcare-associated infections should
be aware of the frequency of these isolates in their hospi-
tal and unit. Then regarding infrequently isolated anaer-
obes such as Bacteroides fragilis group, we suggest to
cover these organisms empirically when a biliary-enteric
anastomosis is present [49].
For grade I and II community-acquired cholangitis and
cholecystitis, Table 3 provides the agents appropriate for
use. Clindamycin resistance among Bacteroides spp. is
significant and the use of clindamycin is no longer recom-
mended in other intra-abdominal infections [49]. Cefox-
itin, cefmetazole, flomoxef, and cefoperazone/sulbactam
are the agents in cephalosporins that have activities
against Bacteroides spp. Cefoxitin is no longer recom-
mended by the SIS-NA/IDSA 2010 guidelines due to high
prevalence of resistance among Bacteroides spp. [49].
Local availability of agents as well as local susceptibility
results are emphasized when choosing empirical therapy.
Table 4 Antimicrobial agents with high prevalence of resistance
among Enterobacteriaceae (endorsed from the Tokyo Guidelines
2013 [1], Table 4)
Antimicrobial class Antimicrobial agents
Penicillin Ampicillin/sulbactam
Cephalosporins Cefazolin
Cefuroxime
Cefotiam
Cefoxitin
Cefmetazole
Flomoxef
Ceftriaxonea
or Cefotaximea
Fluoroquinolones Ciprofloxacin
Levofloxacin
Moxifloxacin
Table 4 is cited from the Tokyo Guidelines 2013 (TG13) [1]
References [14, 31–35]
a
This resistance indicates global spread of extended-spectrum b-lac-
tamase (ESBL)-producing Enterobacteriaceae
8 J Hepatobiliary Pancreat Sci (2018) 25:3–16
7. Table 4 summarizes antimicrobial agents with high
prevalence of resistance among Enterobacteriaceae [29,
31–37]. Ampicillin/sulbactam is one of the most fre-
quently used agents for intra-abdominal infections.
Nonetheless, the activity of ampicillin/sulbactam against
E. coli, with or without ESBLs, has fallen to levels that
prevent a recommendation for its use.
In the TG18, ampicillin/sulbactam is not recommended
as empirical therapy if the local susceptibility is <80%. It
is reasonable to use ampicillin/sulbactam as definitive
therapy when the susceptibility of this agent is proven.
Ampicillin/sulbactam may be used if susceptibility testing
results are available.
Fluoroquinolone use is only recommended if the suscep-
tibility of cultured isolates is known since antimicrobial
resistance has been increasing significantly [29, 31–37].
This agent can also be used as an alternative agent for
patients with b-lactam allergies.
Antimicrobial agents appropriate for use in the
management of healthcare-associated acute cholangitis
and cholecystitis
Since 2010, there have been very few clinical studies on
antimicrobial therapy for patients with healthcare-asso-
ciated acute cholangitis and cholecystitis.
There is no evidence to support any agent as optimal
treatment of healthcare-associated acute cholangitis and
cholecystitis. The principles of empirical therapy of health-
care-associated infections include using agents with anti-
pseudomonal activity until definitive causative organisms
are found.
The local prevalence of ESBL and/or carbapenemase
producing Enterobacteriacea is critical information in
selecting empirical agents. Optimal agents vary from insti-
tution to institution. Therefore, it is underscored that local
susceptibility should be monitored strictly and periodically.
A multi-disciplinary approach would be beneficial to
provide and discuss appropriate antimicrobial agents in
the institution, region, and country.
Table 3 provides empirical agents (presumptive therapy)
for healthcare-associated acute cholangitis and cholecystitis.
Vancomycin is recommended when patients are colonized
with resistant Gram-positive bacteria such as methicillin-
resistant Staphylococcus aureus and/or Enterococcus spp.
or these multidrug-resistant Gram-positives are of concern.
Staphylococcus aureus is not a common isolate for acute bil-
iary infections as Enterococcus spp. In recent study, Staphy-
lococcus aureus was isolated less than 1% both from blood
and bile for patients with acute cholangitis [8].
Vancomycin resistant Enterococcus (VRE) should be
covered empirically with linezolid or daptomycin if this
organism is known to be colonizing the patient, if previ-
ous treatment included vancomycin, and/or if the organ-
ism is common in the community.
Isolation of Bacteroides fragilis group was 1.1% from
blood cultures, and 1.6% from bile cultures among
patients with acute cholangitis [8]. For empirical therapy
for anaerobes such as the Bacteroides fragilis group, we
suggest to cover these organisms empirically in the pres-
ence of a biliary-enteric anastomosis [49].
Is it necessary for agents used in acute biliary
infections to be concentrated in bile?
Historically, biliary penetration of agents has been consid-
ered in the selection of antimicrobial agents. However,
there is considerable laboratory and clinical evidence that
as obstruction occurs, secretion of antimicrobial agents
into bile stops [10]. Recent international guidelines for
acute calculous cholecystitis summarized the bile to serum
concentration ratio and recommend to select agents with
good infected sites penetration [50]. Well-designed ran-
domized clinical trials comparing agents with or without
good biliary penetration are needed to determine the clini-
cal relevance and significance of biliary penetration in
treating acute biliary infections.
How should highly resistant causative organisms be
managed in treating acute cholangitis and
cholecystitis?
Extended-spectrum beta-lactamases-producing E. coli is
highly susceptible to carbapenems and to tigecycline. In
multiple areas of the world, highly resistant Klebsiella
spp. and E. coli with carbapenemases are seen [41, 67–
69]. The widely accepted rule for empirical therapy is that
resistant organisms occurring in more than 10–20% of
patients should be treated. Colistin is the salvage agent for
the above multidrug-resistant Gram-negative bacilli epi-
demic strains [55, 69]. This agent is toxic, dosing is
uncertain, and its use should involve consultation with
infectious disease specialists [55]. Newer agents such as
ceftazidime/avibactam and ceftolozane/tazobactam has
limited evidence for use among patients with acute
cholangitis and cholecystitis.
In TG18, endorsed from TG13 [1], carbapenems, piper-
acillin/tazobactam, and ceftazidime or cefepime, each
combined with metronidazole have been recommended
when the prevalence of resistant Pseudomonas aerugi-
nosa, ESBL-producing Enterobacteriaceae, Acinetobacter
or other multidrug-resistant Gram-negative bacilli is less
than 20% [49]. For ESBL-producing Enterobacteriaceae,
J Hepatobiliary Pancreat Sci (2018) 25:3–16 9
8. carbapenems, piperacillin/tazobactam, and aminoglyco-
sides are recommended. For Pseudomonas aeruginosa, if
the prevalence of resistance to ceftazidime is more than
20%, carbapenems, piperacillin/tazobactam, and aminogly-
cosides are empirically recommended until culture and
susceptibility testing results are available.
Q3. What is the optimal duration and route of antimi-
crobial therapy for patients with acute cholangitis?
Once the source of infection is controlled, antimi-
crobial therapy for patients with acute cholangitis
is recommended for the duration of 4 to 7 days.
(Recommendation 1, level C)
Literature was searched using PubMed and Cochrane
Library using the key words of (acute cholangitis* OR
acute biliary tract infections*) AND (antimicrobial ther-
apy* OR antibiotics*) AND duration of therapy.* MeSH
was also used for each word. There was a total of 151 ar-
ticles from PubMed, 16 from Cochrane Controlled Clini-
cal Trials (CCT), and one from Cochrane Clinical
Database of Systematic Reviews (CDSR). Among them,
selection criteria were either randomized studies or obser-
vational studies. The articles that met the selection criteria
were screened initially by title, then if it was difficult to
judge, the abstract was also reviewed. As a result, there
were four relevant articles found.
Uno et al. [70] compared retrospectively the outcomes
among patients with bacteremic acute cholangitis due to
Gram-negative bacilli who received antimicrobial therapy
over either 14 or 10 days. There were no differences
between the two groups in 30-day mortality and recurrence
rate within 3 months. There were statistically significant dif-
ferences in the lengths of stay (17.5 days vs. 14 days,
P < 0.01). van Lent et al. [71] reported that in their single
institution, there were no differences in the recurrence rate
for acute cholangitis between the patients who received less
than 3-day therapy versus more than 5-day therapy once the
source of infection was controlled among patients with
acute cholangitis. Kogure et al. [72] conducted a prospec-
tive observational study to investigate how long antimicro-
bial therapy should be administered for patients with acute
cholangitis after successful biliary drainage. In this study,
18 patients were analyzed for recurrent cholangitis within
3 days after discontinuing antimicrobial therapy. There
were no recurrences noted. Park et al. [73] conducted a
randomized study to compare the recurrence rate and
30-day mortality among patients with bacteremic cholangi-
tis due to ciprofloxacin-susceptible Enterobacteriacae who
Table
5
Recommended
duration
of
antimicrobial
therapy
Community-acquired
biliary
infections
Healthcare-associated
biliary
infections
Severity
and
diagnosis
Grade
I
and
II
cholecystitis
Grade
I
and
II
cholangitis
Grade
III
cholangitis
and
cholecystitis
Grade
I,
II,
III
healthcare-associated
cholangitis
and
cholecystitis
Duration
of
therapy
Antimicrobial
therapy
can
be
discontinued
within
24
h
after
cholecystectomy
is
performed.
Once
source
of
infection
is
controlled,
duration
of
4–7
days
is
recommended.
If
bacteremia
with
Gram-positive
cocci
such
as
Enterococcus
spp.,
Streptococcus
spp.
is
present,
duration
of
minimum
2
weeks
is
recommended.
If
bacteremia
with
Gram-positive
cocci
such
as
Enterococcus
spp.,
Streptococcus
spp.
is
present,
duration
of
minimum
2
weeks
is
recommended.
Specific
conditions
for
extended
therapy
Perforation,
emphysematous
changes,
and
necrosis
of
gallbladder
are
noted
during
cholecystectomy,
duration
of
4–7
days
is
recommended.
Residual
stones
or
obstruction
of
the
bile
tract
are
present,
treatment
should
be
continued
until
these
anatomic
problems
are
resolved.
If
liver
abscess
is
present,
treatment
should
be
continued
until
clinical,
biochemical
and
radiological
follow-up
demonstrates
complete
resolution
of
the
abscess.
10 J Hepatobiliary Pancreat Sci (2018) 25:3–16
9. underwent successful biliary drainage and received either
conventional intravenous therapy or 6-day intravenous
antimicrobial therapy followed by oral therapy. In this
study, there were no differences between the two groups in
the recurrence of cholangitis and 30-day mortality. In the
TG18, the duration of therapy for patients with acute
cholangitis is for 4 to 7 days once the source of infection is
controlled by integrating the above studies and expert
opinion (Table 5). When bacteremia with Gram-positive
bacteria such as Enterococcus spp. and Streptococcus spp.
is present, it is prudent to offer antimicrobial therapy for
2 weeks since these organisms are well-known to cause
infective endocarditis. The incidence of endocarditis among
patients with acute cholangitis has been reported 17 (0.3%)
out of 6,147 patients with acute cholangitis [8].
In June 2017, the 6th
Asian Pacific Hepatobiliary Pan-
creatic Surgery Conference was held and a clinical ques-
tion was asked among the expert panel, with successful
biliary drainage, how long would you administer antimi-
crobial therapy for patients with bacteremic acute cholan-
gitis due to Gram-positive cocci? Five answers were
provided, such as A: 14 days, B: 10 days, C: 7 days, D:
4–5 days, and E: 3 days or less. The answers were as fol-
lows. A 9%, B 3.8%, C 26.9%, D 32.1%, and E 26.9%.
Q4. What is the optimal duration of antimicrobial
therapy for patients with acute cholecystitis?
Antimicrobial therapy for patients with Grade I
and II acute cholecystitis is recommended only
before and at the time of surgery. (Recommenda-
tion 1, level B)
Once the source of infection is controlled, antimi-
crobial therapy for patients with Grade III acute
cholecystitis is recommended for the duration of 4
to 7 days. (Recommendation 2, level D)
Literature was searched using PubMed and Cochrane
Library using the key words of (acute cholecystitis* OR
acute biliary tract infections*) AND (antimicrobial
therapy* OR antibiotics*) AND duration of therapy.*
MeSH was also used for each word.
There was a total of 51 articles from PubMed, 21 from
CCT, and one from CDSR. Among them, selection crite-
ria were either randomized studies or observational stud-
ies. The articles that met the selection criteria were
screened initially by title, then if it was difficult to judge,
the abstract was also reviewed. As a result, there were
four relevant articles found: three randomized controlled
trials (RCTs) [74–76] and one observational study [77].
TG13 [1] and SIS-IDSA 2010 [49] recommended post-
operative antimicrobial therapy for different durations,
ranging from 24 h to 7 days depending on the severity of
cholecystitis given the lack of high-quality evidence.
Recently, two RCTs assessing the non-inferiority of no
postoperative antimicrobial therapy with postoperative
antimicrobial therapy for patients with mild or moderate
acute cholecystitis who underwent early cholecystectomy
were conducted [74, 75]. Although non-inferiority was
not proven in either RCT, there was no clinically signifi-
cant difference. The results of the two RCTs were inte-
grated and the risk difference for postoperative infection
was 0.01 (95% CI #0.04–0.06) (Fig. 1). Considering the
disadvantages of extended antimicrobial therapy, including
increased medical costs, prolonged hospital stay, and
increased bacterial resistance, the antimicrobial therapy
should be limited to before and at the time of surgery for
Grade I and II acute cholecystitis. Some patients would
need extended postoperative antibiotics depending on their
condition.
For Grade III acute cholecystitis, there are scarce data
available. Hence, we suggest the expert opinion of contin-
uing antimicrobial therapy for 4–7 days after the source
of infection is controlled (Table 5). When bacteremia with
Gram-positive bacteria is present, administering antimicro-
bial therapy for 2 weeks is prudent and recommended to
decrease the risk of infective endocarditis.
In the consensus meeting, there was a statement by the
member that there were no sufficient data to support this
duration of therapy for patients with Grade III acute
cholecystitis, and that it would be difficult to recommend
this.
Fig. 1 This meta-analysis was performed by integrating two randomized studies, references [74] and [75]
J Hepatobiliary Pancreat Sci (2018) 25:3–16 11
10. (Antimicrobial therapy for special conditions)
In patients with pericholecystic abscesses or perfo-
ration of the gallbladder, treatment with an
antimicrobial regimen as listed in Table 3 is rec-
ommended. Therapy should be continued until the
patient is afebrile, with a normalized white count,
and without abdominal findings. (Recommendation
1, level D)
In most cases, cholecystectomy removes the infection,
and little if any infected tissue remains. Under these cir-
cumstances, there is no benefit to antimicrobial therapy
extending beyond 24 h [74, 75].
Randomized clinical trials for antimicrobial therapy of
acute cholecystitis are limited [60, 62–65]. In these ran-
domized studies, comparisons were made such as ampi-
cillin plus tobramycin versus piperacillin or cefoperazone,
pefloxacin versus ampicillin and gentamicin, cefepime
versus mezlocillin plus gentamicin [14, 60, 63, 65]. There
were no significant differences between the agents com-
pared. In the TG18, the agents considered as appropriate
therapy, and listed in Table 3, have all been used in RCTs
of intra-abdominal infections. These studies included
patients with pathologically advanced cholecystitis (abscess
or perforation). Table 3 is provided for both community-
acquired and healthcare-associated acute cholecystitis.
Antimicrobial therapy after susceptibility testing
results are available
Once susceptibility testing results of causative microor-
ganisms are available, specific therapy (or definitive
therapy) should be offered. This process is called de-esca-
lation [7]. Agents in Table 4 can be used safely once the
susceptibility is proven.
Conversion to oral antimicrobial agents
Patients with acute cholangitis and cholecystitis who can
tolerate oral feeding may be treated with oral therapy
[78]. Depending on the susceptibility patterns of the
organisms identified, oral antimicrobial agents such as flu-
oroquinolones (ciprofloxacin, levofloxacin, or moxi-
floxacin), amoxicillin/clavulanic acid, or cephalosporins
may also be used. Table 6 lists commonly used oral
antimicrobial agents with good bioavailabilities.
Use of antibiotic irrigation
There has been continuing interest in irrigation of surgical
fields with antimicrobial agents, and the subject has
recently been reviewed [79]. The authors concluded that
topical antimicrobial agents are clearly effective in reduc-
ing wound infections and may be as effective as the use
of systemic antimicrobial agents. The combined use of
systemic and topical antimicrobial agents may have addi-
tive effects, but this is lessened if the same agent is used
for both topical and systemic administration.
Conclusions
In TG18, antimicrobial agents appropriate for use as
empirical therapy for community-acquired and healthcare-
associated infections are provided. Globally increasing
and spreading antimicrobial resistance, antimicrobial stew-
ardship should be underscored and implemented for pru-
dent antimicrobial usage in each institution. Local,
national, and international continuous monitoring of
antibiogram would provide safe and appropriate therapy
for patients with acute cholangitis and cholecystitis in a
timely fashion. More definitive studies to indicate the
appropriate duration of antimicrobial therapy for patients
with bacteremic cholangitis and cholecystitis are
warranted.
Acknowledgments We express our deep gratitudes to the Japanese
Society of Hepato-Biliary-Pancreatic Surgery, the Japanese Society
of Abdominal Emergency Medicine, the Japanese Society of
Surgical Infection, the Japan Biliary Association, for their substantial
support and guidance in the preparation of the article. We would
also like to express our deep gratitude to the Japanese Society of
Hepato-Biliary-Pancreatic Surgery for the article processing
managing office of Tokyo Guidelines 2018 to prepare the
publication. We appreciate all secretariats of the Japanese Society of
Hepato-Bilialy-Pancreatic Surgery for their technical support.
Conflict of interest Goro Honda has received honoraria from
Johnson and Johnson and Medtronic.
Table 6 Representative oral antimicrobial agents for community-
acquired and healthcare-associated acute cholangitis and cholecystitis
with susceptible isolates (endorsed from the Tokyo Guidelines 2013
[1], Table 6)
Antimicrobial class Antimicrobial agents
Penicillins Amoxicillin/clavulanic acid
Cephalosporins Cephalexin
" Metronidazolea
Fluoroquinolones Ciprofloxacin
or Levofloxacin
" Metronidazolea
Moxifloxacin
a
Anti-anaerobic therapy, including use of metronidazole, tinidazole, or
clindamycin, is warranted if a biliary-enteric anastomosis is present
12 J Hepatobiliary Pancreat Sci (2018) 25:3–16
11. Appendix: author’s affiliations
Harumi Gomi, Center for Global Health, Mito Kyodo
General Hospital, University of Tsukuba, Ibaraki, Japan;
Joseph S. Solomkin, Department of Surgery, University of
Cincinnati College of Medicine, Cincinnati, OH, USA;
David Schlossberg and Henry A. Pitt, Lewis Katz School
of Medicine at Temple University, Philadelphia, PA,
USA; Kohji Okamoto, Department of Surgery, Center for
Gastroenterology and Liver Disease, Kitakyushu City
Yahata Hospital, Fukuoka, Japan; Tadahiro Takada,
Fumihiko Miura and Keita Wada, Department of Surgery,
Teikyo University, School of Medicine, Tokyo, Japan;
Steven M. Strasberg, Section of HPB Surgery, Washing-
ton University in St. Louis, St. Louis, MO, USA; Tomo-
hiko Ukai, Department of Family Medicine, Mie
Prefectural Ichishi Hospital, Mie, Japan; Itaru Endo,
Department of Gastroenterological Surgery, Yokohama
City University Graduate School of Medicine, Kanagawa,
Japan; Yukio Iwashita and Masafumi Inomata, Depart-
ment of Gastroenterological and Pediatric Surgery, Oita
University Faculty of Medicine, Oita, Japan; Taizo Hibi,
Department of Surgery, Keio University School of Medi-
cine, Tokyo, Japan; Naohisa Matsunaga, Department of
Infection Control and Prevention, Teikyo University,
Tokyo, Japan; Yoriyuki Takamori, Department of Internal
Medicine, Teikyo University School of Medicine, Tokyo,
Japan; Akiko Umezawa, Minimally Invasive Surgery
Center, Yotsuya Medical Cube, Tokyo, Japan; Koji Asai,
Department of Surgery, Toho University Ohashi Medical
Center, Tokyo, Japan; Kenji Suzuki, Department of
Surgery, Fujinomiya City General Hospital, Shizuoka,
Japan; Ho-Seong Han and Yoo-Seok Yoon, Department
of Surgery, Seoul National University Bundang Hospital,
Seoul National University College of Medicine, Seoul,
Korea; Tsann-Long Hwang, Miin-Fu Chen and Keng-Hao
Liu, Division of General Surgery, Linkou Chang Gung
Memorial Hospital, Taoyuan, Taiwan; Yasuhisa Mori,
Department of Surgery and Oncology, Graduate School of
Medical Sciences, Kyushu University, Fukuoka, Japan;
Wayne Shih-Wei Huang, Department of Surgery, Show
Chwan Memorial Hospital, Changhua, Taiwan; Giulio
Belli, Department of General and HPB Surgery, Loreto
Nuovo Hospital, Naples, Italy; Christos Dervenis, First
Department of Surgery, Agia Olga Hospital, Athens,
Greece; Masamichi Yokoe and Yoshinori Noguchi,
Department of General Internal Medicine, Japanese Red
Cross Nagoya Daini Hospital, Aichi, Japan; Seiki Kir-
iyama, Department of Gastroenterology, Ogaki Municipal
Hospital, Gifu, Japan; Takao Itoi and Shuntaro Mukai,
Department of Gastroenterology and Hepatology, Tokyo
Medical University Hospital, Tokyo, Japan; Palepu
Jagannath, Department of Surgical Oncology, Lilavati
Hospital and Research Centre, Mumbai, India; O James
Garden, Clinical Surgery, University of Edinburgh, Edin-
burgh, UK; Eduardo de Santiba~
nes, Department of Sur-
gery, Hospital Italiano, University of Buenos Aires,
Buenos Aires, Argentina; Satoru Shikata, Director, Mie
Prefectural Ichishi Hospital, Mie, Japan; Goro Honda,
Department of Surgery, Tokyo Metropolitan Komagome
Hospital, Tokyo, Japan; Avinash Nivritti Supe, Depart-
ment of Surgical Gastroenterology, Seth G S Medical Col-
lege and K E M Hospital, Mumbai, India; Masahiro
Yoshida, Department of Hemodialysis and Surgery, Ichi-
kawa Hospital, International University of Health and
Welfare, Chiba, Japan and Department of EBM and
Guidelines, Japan Council for Quality Health Care,
Tokyo, Japan; Toshihiko Mayumi, Department of Emer-
gency Medicine, School of Medicine University of Occu-
pational and Environmental Health, Fukuoka, Japan; Dirk
J. Gouma, Department of Surgery, Academic Medical
Center, Amsterdam, The Netherlands; Daniel J. Deziel,
Department of Surgery, Rush University Medical Center,
Chicago, IL, USA; Kui-Hin Liau, Liau KH Consulting
PL, Mt Elizabeth Novena Hospital, Singapore, Yong Loo
Lin School of Medicine, National University of Singapore,
Singapore; Cheng-Hsi Su, Department of Surgery, Cheng
Hsin General Hospital, Taipei, Taiwan; Angus C. W.
Chan, Surgery Centre, Department of Surgery, Hong Kong
Sanatorium and Hospital, Hong Kong, Hong Kong; Dong-
Sup Yoon, Department of Surgery, Yonsei University
Gangnam Severance Hospital, Seoul, Korea; In-Seok Choi,
Department of Surgery, Konyang University Hospital,
Daejeon, Korea; Eduard Jonas, Surgical Gastroenterology/
Hepatopancreatobiliary Unit, University of Cape Town and
Groote Schuur Hospital, Cape Town, South Africa; Xiao-
Ping Chen, Hepatic Surgery Centre, Department of Sur-
gery, Tongji Hospital, Tongji Medical College, Huazhong
University of Science and Technology, Wuhan, China;
Sheung Tat Fan, Director, Liver Surgery Centre, Hong
Kong Sanatorium and Hospital, Hong Kong, Hong Kong;
Chen-Guo Ker, Department of Surgery, Yuan’s General
Hospital, Kaohsiung, Taiwan; Mariano Eduardo Gim!
enez,
Chair of General Surgery and Minimal Invasive Surgery
“Taquini”, University of Buenos Aires, DAICIM Founda-
tion, Buenos Aires, Argentina; Seigo Kitano, President,
Oita University, Oita, Japan; Ryota Higuchi and Masakazu
Yamamoto, Department of Surgery, Institute of Gastroen-
terology, Tokyo Women’s Medical University, Tokyo,
Japan; Koichi Hirata, Department of Surgery, JR Sapporo
Hospital, Hokkaido, Japan; Kazuo Inui, Department of
Gastroenterology, Second Teaching Hospital, Fujita Health
University, Aichi, Japan; Yoshinobu Sumiyama, Director,
Toho University, Tokyo, Japan.
J Hepatobiliary Pancreat Sci (2018) 25:3–16 13
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